| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
436 |
427 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
31 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
12 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
271 |
264 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
97 |
$3K |
| D0274 |
Bitewings - four radiographic images |
122 |
116 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
26 |
$898.92 |